MED SURG GASTROINTESTINAL
NCLEX QUESTIONS WITH
VERIFIED ANSWERS
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this
client? Select all that apply.
A. Administer stool softeners as prescribed.
B. Instruct the client to limit fluid intake to avoid urinary retention.
C. Encourage a high-fiber diet to promote bowel movements without straining.
D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
E. Help the client to a Fowler's position to place pressure on the rectal area and decrease
bleeding. - ANSWER --A. Administer stool softeners as prescribed.
C. Encourage a high-fiber diet to promote bowel movements without straining.
D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
Rationale:
Nursing interventions after a hemorrhoidectomy are aimed at management of pain and
avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the
client to avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will
increase comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is
scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and
begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel
sounds are diminished. Which is the most appropriate nursing intervention?
,A. Notify the health care provider (HCP).
B. Administer the prescribed pain medication.
C. Call and ask the operating room team to perform surgery as soon as possible.
D. Reposition the client and apply a heating pad on the warm setting to the client's abdomen. -
ANSWER --A. Notify the health care provider (HCP).
Rationale:
On the basis of the signs and symptoms presented in the question, the nurse should suspect
peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention.
Heat should never be applied to the abdomen of a client with suspected appendicitis because of
the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although
the HCP probably would perform the surgery earlier than the prescheduled time.
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about
substances to avoid. Which items should the nurse include on this list? Select all that apply.
A. Coffee
B. Chocolate
C. Peppermint
D. Nonfat milk
E. Fried chicken
F. Scrambled eggs - ANSWER --A. Coffee
B. Chocolate
C. Peppermint
E. Fried chicken
Rationale:
,Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will
increase reflux and exacerbate the symptoms of GERD and therefore should be avoided.
Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated
beverages, and alcohol. Options 4 and 6 do not promote this effect.
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding
would most likely indicate perforation of the ulcer?
A. Bradycardia
B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, boardlike abdomen - ANSWER --D. A rigid, boardlike abdomen
Rationale:
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable
severe pain beginning in the mid-epigastric area and spreading over the abdomen, which
becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as
hypovolemic shock develops. Numbness in the legs is not an associated finding.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which
postoperative prescription should the nurse question and verify?
A. Leg exercises
B. Early ambulation
C. Irrigating the nasogastric tube
D. Coughing and deep-breathing exercises - ANSWER --C. Irrigating the nasogastric tube
, Rationale:
In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is
anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing
the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube
after gastric surgery, unless specifically prescribed by the health care provider. In this situation,
the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative
interventions.
The nurse is providing discharge instructions to a client following gastrectomy and should
instruct the client to take which measure to assist in preventing dumping syndrome?
A. Ambulate following a meal.
B. Eat high-carbohydrate foods.
C. Limit the fluids taken with meals.
D. Sit in a high Fowler's position during meals. - ANSWER --C. Limit the fluids taken with
meals.
Rationale:
Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs
after eating, especially following a gastrojejunostomy (Billroth II procedure). Early
manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia,
syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the
client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods,
including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie
down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as
prescribed.
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority
on which item as part of the client's care plan?
1. Monitoring the temperature
NCLEX QUESTIONS WITH
VERIFIED ANSWERS
A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this
client? Select all that apply.
A. Administer stool softeners as prescribed.
B. Instruct the client to limit fluid intake to avoid urinary retention.
C. Encourage a high-fiber diet to promote bowel movements without straining.
D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
E. Help the client to a Fowler's position to place pressure on the rectal area and decrease
bleeding. - ANSWER --A. Administer stool softeners as prescribed.
C. Encourage a high-fiber diet to promote bowel movements without straining.
D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
Rationale:
Nursing interventions after a hemorrhoidectomy are aimed at management of pain and
avoidance of bleeding and incision rupture. Stool softeners and a high-fiber diet will help the
client to avoid straining, thereby reducing the chances of rupturing the incision. An ice pack will
increase comfort and decrease bleeding. Options 2 and 5 are incorrect interventions.
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is
scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and
begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel
sounds are diminished. Which is the most appropriate nursing intervention?
,A. Notify the health care provider (HCP).
B. Administer the prescribed pain medication.
C. Call and ask the operating room team to perform surgery as soon as possible.
D. Reposition the client and apply a heating pad on the warm setting to the client's abdomen. -
ANSWER --A. Notify the health care provider (HCP).
Rationale:
On the basis of the signs and symptoms presented in the question, the nurse should suspect
peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention.
Heat should never be applied to the abdomen of a client with suspected appendicitis because of
the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although
the HCP probably would perform the surgery earlier than the prescheduled time.
The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about
substances to avoid. Which items should the nurse include on this list? Select all that apply.
A. Coffee
B. Chocolate
C. Peppermint
D. Nonfat milk
E. Fried chicken
F. Scrambled eggs - ANSWER --A. Coffee
B. Chocolate
C. Peppermint
E. Fried chicken
Rationale:
,Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will
increase reflux and exacerbate the symptoms of GERD and therefore should be avoided.
Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated
beverages, and alcohol. Options 4 and 6 do not promote this effect.
The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding
would most likely indicate perforation of the ulcer?
A. Bradycardia
B. Numbness in the legs
C. Nausea and vomiting
D. A rigid, boardlike abdomen - ANSWER --D. A rigid, boardlike abdomen
Rationale:
Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable
severe pain beginning in the mid-epigastric area and spreading over the abdomen, which
becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as
hypovolemic shock develops. Numbness in the legs is not an associated finding.
The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which
postoperative prescription should the nurse question and verify?
A. Leg exercises
B. Early ambulation
C. Irrigating the nasogastric tube
D. Coughing and deep-breathing exercises - ANSWER --C. Irrigating the nasogastric tube
, Rationale:
In a gastrojejunostomy (Billroth II procedure), the proximal remnant of the stomach is
anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing
the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube
after gastric surgery, unless specifically prescribed by the health care provider. In this situation,
the nurse should clarify the prescription. Options 1, 2, and 4 are appropriate postoperative
interventions.
The nurse is providing discharge instructions to a client following gastrectomy and should
instruct the client to take which measure to assist in preventing dumping syndrome?
A. Ambulate following a meal.
B. Eat high-carbohydrate foods.
C. Limit the fluids taken with meals.
D. Sit in a high Fowler's position during meals. - ANSWER --C. Limit the fluids taken with
meals.
Rationale:
Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs
after eating, especially following a gastrojejunostomy (Billroth II procedure). Early
manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia,
syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the
client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods,
including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie
down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as
prescribed.
A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority
on which item as part of the client's care plan?
1. Monitoring the temperature
